Provider Demographics
NPI:1811085459
Name:GASTROINTESTINAL DIAGNOSTIC CLINIC
Entity type:Organization
Organization Name:GASTROINTESTINAL DIAGNOSTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA/MHA
Authorized Official - Phone:702-737-7555
Mailing Address - Street 1:3196 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2305
Mailing Address - Country:US
Mailing Address - Phone:702-369-3400
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY
Practice Address - Street 2:SUITE 207
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2305
Practice Address - Country:US
Practice Address - Phone:702-369-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV477ASC-8261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV9C0001010Medicare PIN